Healers that hurt: a scoping review of media reports of cases of rape in healthcare settings

Background Sexual assault occurring within healthcare settings represents a significant breach of public trust. This scoping review aimed to highlight the profile of people raped, those who committed the rape within the health facilities, and the legal actions taken to resolved cases. Methods Media-reported data on incidents of rape in healthcare settings were collected. The search was conducted in May and June 2023, focusing on English-language publications with accessible full texts. Reports that lacked information on the survivors or incidents that occurred outside of healthcare settings were excluded. Descriptive statistics were used to summarize the categories of the collected publications, and graphical representations were employed for visualization purposes. Results A total of 62 cases were retrieved, originating from Africa (n = 17; 27.4%), Europe (n = 14; 22.6%), Southeast Asia (n = 14; 22.6%), the Americas (n = 11; 17.7%), the Western Pacific Region (n = 5; 8.1%) and Eastern Mediterranean region (n = 1; 1.6%). In addition, 69 individuals were implicated in 59 cases. They were 31 doctors (44.9%), 17 (24.6%) nurses, four (5.8%) nurse/healthcare assistants, three (4.3%) cleaners/ward boy, two (2.9%) traditional medical doctors, and two (2.9%) security guards. Others included six (8.7%) staff members without designations and one (1.4%) ambulance driver. All perpetrators were male, ranging in age from 22 to 67 years. There were 66 victims identified in the 62 cases with age ranging from 2 to 92 years. Except for one case, all victims were female, and all but one case were patients. Most assaults occurred in consulting rooms/clinics (n = 21; 31.8%), 16 (24.2%) happened under sedation, and six (9.1%) were repeatedly raped, Survivors typically reported the cases the police (n = 12; 19.4%), family/friends (n = 11; 17.7%) or to hospital authorities (n = 10; 16.1%). Out of the 69 perpetrators, 19 (30.6%) were imprisoned with sentences ranging from 12 months to an indefinite period and one (1.6%) received a death sentence. Conclusion The raping of patients by healthcare providers within healthcare settings calls for urgent and extensive measures. Stakeholders in healthcare management need to prioritize raising awareness about the problem, implement robust prevention and reporting strategies, and create healthcare environments that are safe, respectful, and supportive for all individuals seeking care. Supplementary Information The online version contains supplementary material available at 10.1186/s40359-024-01721-w.


Introduction
Rape is a grave violation of human rights, causing profound physical, psychological, and emotional harm to survivors [1][2][3].While it is a widely recognized issue in society, there is little known about rape committed within healthcare settings.Healthcare settings, expected to provide care, support, and healing, can become unsafe for patients and staff due to the power dynamics and vulnerabilities inherent in the patient-provider relationship [4,5].This power dynamic can be exacerbated when patients are in vulnerable states, such as during examinations, procedures, or while under anaesthesia [6].In addition, inadequate institutional policies and lack of comprehensive training on preventing and addressing sexual assault contribute to a culture of silence and impunity [6] within the healthcare setting.Furthermore, the absence of standardized reporting mechanisms and support systems for survivors also perpetuates a cycle of victimization and further emboldens perpetrators [6].
Sexual abuse committed by healthcare professionals has significant implications for victims and the healthcare system [7,8].It is an unwelcome traumatic experience that can leave long-term physical and psychological effects making affected individuals feel humiliated, intimidated, or uncomfortable [9], and may trigger or exacerbate serious mental health disorders [10].It also undermines the integrity of the healthcare system, and tarnish the reputation of the medical profession, potentially discouraging individuals from seeking necessary medical attention [11].This, in turn, can have a detrimental impact on public health outcomes, as delayed or avoided medical care can exacerbate existing conditions and lead to negative health consequences [12].
In addition, the perpetration of sexual abuse by healthcare professionals represents a profound breach of trust and an egregious violation of professional ethics.It undermines the foundational principles of medical ethics, including beneficence, non-maleficence, and respect for patient autonomy [13,14].Although comprehensive data on this specific form of sexual assault is limited, numerous studies and anecdotal evidence highlight its existence [15].
While sexual abuse in healthcare setting has been recognised as an occupational hazard for healthcare professionals perpetuated by patients, patients' families, peers, and visitors [16,17], there is little systematic documentation or comprehensive study about patients' experience of sexual abuse within the healthcare setting.The extent of the problem of sexual abuse in healthcare institutions perpetuated by healthcare providers and allies working in the healthcare setting may be larger than recognised.This lack of data makes it difficult to fully understand the scale and scope of the problem; and how to systematically address the problem.
We, however, hypothesised using the feminist theory that rape within healthcare settings is not only a violation of individual rights but also a manifestation of broader power dynamics and inequalities entrenched within patriarchal society.Feminist theory emphasizes that power is unequally distributed along gender lines, contributing to the vulnerability of individuals, particularly women, within institutional settings.The patientprovider relationship, characterized by inherent power differentials, mirrors broader societal structures where women are often marginalized and disempowered.This power dynamic is exacerbated when patients, already in vulnerable states, are subjected to sexual violence by healthcare professionals who abuse their authority.
This aim of this scoping review, therefore, was to identify and synthesize the electronic media reports on rape of patients in healthcare institutions; and to analyse the cases for any observable pattern using relevant theoretical concepts.Specifically, the study highlighted the profile of people raped and those who committed the rape within the health facilities, who reported the case, pattern of how and where rape happened within the healthcare setting, and the legal actions taken to resolved cases.

Methods
The proposed scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [18].We developed our research questions, identified relevant studies using develop search strategies and following the inclusion and exclusion criteria, charted and collated the data, synthesised and developed the results.

Research questions
This scoping review was guided by the questions (1) what is the profile of the survivors raped within healthcare facilities?(2) what is the profile of the perpetuators of rape within healthcare facilities?(3) who reported the cases of rape? and ( 4) what legal responses were provided?

Search strategy
The search was conducted on the internet in between May and June 2023.Supplementary search was conducted in PubMed, Web of Science and Scopus.The search was conducted using the following key terms: "doctor" or "nurses" or "health attendants" or "health workers" and "rape" or "assault" and "patients" and "hospitals" or "clinic".Search terms were updated according to the requirements of each electronic database where required.Details of search strings are accessible in Supplemental File 1.

Eligibility criteria and selection
Literature obtained were exported into the reference management software Mendeley version 1.19.8.Duplicate articles were removed.Title and news content screening were performed independently by two researchers (AN and AI) using pre-defined inclusion and exclusion eligibility criteria.Uncertainty regarding whether publications met the inclusion criteria was resolved through consensus with one of the team members (MOF).No author or institution was contacted to verify the source of information.

Inclusion criteria
Published reports written in English were identified through the searches.Only cases of rape that happened in healthcare settings were extracted.Rape was defined as "The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim." [19,20].

Exclusion criteria
Cases were excluded if there were no profiling of the rape survivor, and if the reports of rape did not take place within a medical care facility.

Data charting
The characteristics of studies including in the review are summarised in Table 1.The details on publishing media house, year of publication, location of the case, were extracted and reported.Other information summarised were the age, sex and status of the rape survivor, the age and sex and profession of the perpetuator, country where rape happened, who reported the case and the legal status of the case.

Data analysis
Descriptive statistics, specifically frequencies and percentages, were used to present data.The countries where the cases were reported were classified by WHO region [21] into the Americas Regions (AMR); Eastern Mediterranean Region (EMR); African Region (AFR), European Region (EUR); Southeast Asian Region (SEAR) and the Western Pacific Region (WPR).

Role of the funding source
The study was funded by out-of-pocket expenses.This had no role to play in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Results
As Fig. 1 indicates, the initial search from 427 reports yielded 114 potentially relevant case reports.Overall, 52 publications were excluded based on the exclusion criteria leaving 62 reports for inclusion in the analysis.

Distribution of cases
Figure 1 shows the distribution of the 62 reports by region while Table 1 shows the country where the incidence happened.The largest number of reports were from the AFR (27.4%)-six from Nigeria, six from South Africa, two from Namibia, and 1 from Ghana, Guinea, and Zambia respectively.This was followed by 14 (22.6%)reports from EUR-10 from the United Kingdom and one case each from France, Greece, Belgium, and Russia; and 14 (22.6%)reports from the SEAR-11 from India, two from Sri Lanka and one from Bangladesh.There were 11 (17.7%)reports from AMR-six from the United States of America, two from Canada and Jamaica respectively, and one from Brazil.There were five (8.1%) reports from WPR-three from Australia, one from Singapore and one from Taiwan.The least number of reports was from the EMR (1.6%)-the single report was from Pakistan.

Temporal analysis
Table 1 shows that the first report dated back to 1973 in India.The most recent cases were reported in 2023-one in AFR (Nigeria) and AMR (Jamaica) respectively.Figure 2 shows that there were seven (11.3%) reports before 2000, four (6.5%) between 2000 and 2010, 40 (64.5%) between 2011 and 2020, and eight (12.9%)cases in the 3 years after 2020.Three (4.8%) of the 62 reports had undisclosed dates of incidence.

Characteristics of perpetrators
Table 1 shows that different personnel in the healthcare institution committed the rapes.Of the 62 cases report, three (4.8%) of the cases had unknown perpetuators, while the remaining 59 cases had 69 perpetuators.These were 31 doctors (44.9%), 17 (24.6%)nurses, four (5.8%) nurse/healthcare assistants, three (4.3%)cleaners/ward boy, two (2.9%) traditional medical doctors, and two (2.9%) security guards.Others included six (8.7%) staff members without designations and one (1.4%)ambulance driver.Four of the cases were gang rapes within the health institutions-one in Guinea and three in India.
Table 1 shows that all identified perpetuators were males.The ages of 36 of the 59 perpetuators identified ranged from 22 years to 67 years with a mean (standard deviation) age of 45.44 (13.97) years.occurred in the consulting room/clinics, eight (12.1%)occurred in the wards, six (9.1%) in nursing homes, four (6.1%) in the accident and emergency, four (6.1%) in theatre/recovery room, four (6.1%) in radiology/scan rooms, two (3.0%) in isolation wards, two (3.0%) in psychiatric hospital/homes, two (3.0%) in intensive care units, one (1.5%) in the ambulance (n = 1) and one (1.5%) in the nursing changing room.However, there were 11 cases where information about the location of the assault within the hospital could not be obtained.In addition, 16 (24.2%)cases of rape happened under sedation-purposefully sedated by perpetuator, or while under general anesthesia.six (9.1%) were repeatedly raped, four (6.1%) died after been raped, two (3.0%) of the victims were blackmailed, and two (3.0%) were strangulated (one lived as a vegetable) after the rape.

As shown in
The media report disclosed the ages of 46 victims, ranging from 2 years to 92 years, with a mean (standard deviation) age of 33.44 (23.39) years.Among the survivors, 15 were children and adolescents and five were elderlies above 60 years of age.All the victims were females, except for one male victim who experienced rape in a psychiatry hospital in South Africa.All the victims were also patients except for one female nurse who was raped in the nurses changing room in India.Patients molested include those with disability (n = 4), those with mental health challenges (n = 3), those unconscious (n = 3), those with communicable disease (n = 3), on ventilator (n = 1) and autistic (n = 1).

Disclosure and Legal outcomes
Of the 62 cases, 18 (29.0%)reported the incidents of which 12 (19.4%)were reported to the police, 11 (17.7%) to family or friends, 10 (16.1%) to hospital authorities, and two (3.2%) to both the police and family.Seven (11.3%) cases could not have made reports because they were either killed, unconscious or had severe disabilities.One reported to the media (1.6%) and one (1.6%) was discovered through other investigations.
The legal outcomes of the 62 cases were as follows: one (1.6%) received a death sentence, 18 (29.0%)led to imprisonment with sentences ranging from 12 months to an indefinite period, two (3.2%) were placed on probation, one (1.6%) received a reprimand from the court, and three (4.8%) was convicted but no details about the length of the jail term were provided.Additionally, one (1.6%)case was awarded a compensation of £100,000 per year for 2 years.Regarding the status of the other perpetrators at the time of the media reports, eight (12.9%) had been arrested, seven (11.2%) had been charged and were awaiting trial, six (9.7%) were under ongoing investigations, three (4.8%) were fugitives, two (3.2%) was scheduled to be charged, one (1.6%)could not be located, and one (1.6%) had a preliminary determination of 'no rape' by the investigating medical officer.One perpetrator (1.6%) committed suicide a week after the allegation.Information on actions being taken against seven perpetrators (11.3%) was unavailable.

Discussion
Our review of the scope of rape cases in healthcare facilities suggests that it is a global problem, perpetuated by health care workers and non-healthcare workers in healthcare facilities and nursing homes.Most of the perpetrators were male and middle-aged, utilizing their positions of authority as healthcare providers to gain access to the victims.Females are worse affected, and when reported, receive poor legal attention.Furthermore, the study revealed that only one out of four cases reported by the media resulted in a conclusive legal determination.This suggests that a significant number of cases did not reach a resolution at the time of media reporting.This is the first study that undertook a review of cases of rape perpetuated in health facilities.The review, however, has a few limitations.First, the scope was limited to case reports written in English and those reports accessible on the internet.These criteria lead to the exclusion of some reports, including those reported to legal authorities but not captured by the media, and those reported in media outlets not accessible on the internet.In addition, the use of the search term 'health workers' may not have captured the diverse range of healthcare workers in the health sector.these gaps could have led to the underreporting of the cases.Despite this risk of under-reporting, the review highlights a few critical findings.
First, health care settings are critical site for connecting survivors to care [22].That rape happens within healthcare settings, that patients who need care for rape are raped within healthcare settings [23], and that healthcare providers are the major perpetuators is a major concern.The breach of trust by a trusted healthcare professional can lead to profound trauma, eroding their sense of safety and security.Survivors may experience mental health disorders such as post-traumatic stress disorder, anxiety, depression, and may also have difficulty seeking future medical care, often leading to delayed or neglected treatment [2,7].This finding highlights the need to identify systems related factors that enable such abuse; measures that can be instituted to prevent and break the culture of silence on rape of patients by healthcare workers and allies in health facilities; and systems that need to be put in place to reduce the risk of patients being exploited by those who work in the health care institutions.
The study findings indicates that abuse happens most frequently in the consulting room within healthcare settings.The consulting room is intended to be a safe and professional environment where patients seek medical care and treatment.The practice of doctors having chaperones when seeing patients should reduce this risk of rape [24,25] though there were cases where the rape happened immediately after the chaperone left the office for official duties [26,27].The possibility for rapes to happen even when chaperones are designated to clinics, suggests the need for institution of strict practice protocols, enhancing staff training on ethical conduct and professional boundaries, promoting a culture of zero tolerance for abuse, and establishing effective mechanisms for identifying.reporting and addressing incidents and suspected cases of abuse by patients and staff.
One system for prompt identifying of cases is for hospitals to invest in the use of technologies that enables the non-intrusive monitoring of what goes on in the consulting rooms, wards, and theatres as an additional safeguard measure for patients.This does not preclude instituting systems and processes that promotes the culture of accountability among the staff in the hospital; the strengthening of policies and procedures that prevents sexual harassment of patients and the prompt reporting of cases to appropriate authorities; providing regular education and training to healthcare professionals; and supporting survivors with appropriate resources and services.
Second, we observe that victims of rape may turn to the family/friends, hospital authorities or the police as the person first notified.It is therefore important that the competencies of those often notified should be built to properly address cases, especially in ways which effectively support the healing of the survivor.Although perpetuators may want to settle cases out of court, they should face the civil or criminal justice systems in pursuit of legal justice on behalf of the victims, and as a deterrent for a repeat.Survivors also need informal support groups post-assault, to navigate the civil and criminal justice systems, cope with the traumatic experience they have endured, and in interpreting these experiences [28].Furthermore, the legal systems need to be strengthened to ensure that survivors of sexual violence have access to justice and support services.
Public discussions and awareness of the possibility of sexual assaults and harassment in the confines of hospital, can also help to improve the judiciary system for handling these cases.Ensuring that perpetrators are held accountable for their actions through legal and disciplinary measures is also essential to prevent further instances of abuse and to restore trust in the healthcare system.It is also important to foster a culture that supports and believes survivors, while challenging societal attitudes that perpetuate victim-blaming and stigma [29].
Sexual abuse by health care professionals is very likely to be underreported because of factors such as fear, shame, power imbalances, and concerns about retaliation or not being believed [30,31].Often, the stigma of sexual abuse is on the survivor who having survived the abuse, is often unable to survive the social repercussions associated with reporting.Shame often leads to foregoing medical and legal help to avoid further humiliation [9].In addition, survivors may also not realize that what was happening was wrong, illegal, or a form of abuse [32].Furthermore, it is a lot more difficult to report sexual abuse perpetuated by persons in the position of power and trust like a healthcare provider.Healthcare workers are granted access to their patients' bodies and should only use that access in a manner appropriate for medical care.Often, the onus then lies with the survivor to prove that the health professional's access to the patient's body was in a manner inappropriate for medical care.This abuse of power underscores the urgency of addressing the issue.
Third, we noticed a tremendous increase in the number of reported cases between 2011 and 2020 when compared to the previous decade, and a high rising number in the years after 2020.We feel this increase in the number of reports may be due to several factors, including heightened awareness and advocacy efforts, improved reporting mechanisms, changes in societal attitudes towards reporting, and possibly an actual increase in the incidence of the observed phenomena.Further studies are needed to understand this observation as the findings may help to strengthen public response to preventing and addressing the rape of patients in health institutions.In addition, future studies should also investigate the observed syndemic nature of rape within healthcare institutions.This encompasses not only instances of sexual assault against females but also the rape of females who are vulnerable such as those with disabilities, the elderly and sedated patients as highlighted in this study.
This study highlights that within the healthcare setting, there exist diverse populations of rapists who may exhibit distinct motivations and psychological characteristics [33].We postulate that rapists in the healthcare sector represent a population with psychological traits that have received limited research attention.These individuals may demonstrate low self-control, impulsivity, a penchant for adventure, self-centeredness, and a tendency to engage in immediate gratification through criminal acts, as proposed by the self-control theory [34].The use of sedatives by some healthcare rapists or the act of raping victims under general anaesthesia can be likened to using force to obtain sexual satisfaction, as described by the Narcissistic Reactance Theory [35].However, it is important to note that the context in which rape occurs in the healthcare setting does not align with the Narcissistic Reactance Theory's premise that forceful sex is a reaction to a refusal of sexual advances by the victim.Similarly, the actions of healthcare providers who commit rape do not align with the Feminist Theory, which posits that rape is a conscious process of intimidation aimed at keeping women in a state of fear [36].In addition, the dynamics of rape within the healthcare setting do not completely support the idea of perpetuators wanting to instil fear in victims though the cases that used blackmail to keep their hold over the survivors to enable them to continue to rape, may suggest otherwise.Our findings suggest that healthcare workers who commit rape view their victims as easy targets for satisfying their sexual urges, with little regard for the health and well-being of the victims.
However, it is crucial to acknowledge the limitations of applying theoretical frameworks to the unique context of healthcare-related sexual abuse.While elements of selfcontrol theory may offer insights into the motivations of perpetrators, the dynamics of power and vulnerability within healthcare settings complicate traditional understandings of rape as solely an expression of individual pathology or deviance.Moreover, the intersectionality of factors such as race, gender, age, and disability further shape the experiences of survivors and the responses of healthcare institutions.The events reported in this scoping review, however, suggests the lack of comprehensive institutional policies and training to address sexual assault.This reflects a systemic failure to prioritize the safety and well-being of survivors, further perpetuating a culture of silence and impunity.While the healthcare setting may appear safe in public, they pose a risk to vulnerable populations, as evidenced by the profile of the rape victims in this study.
Moving forward, it is imperative to address the systemic failures and institutional barriers that enable sexual abuse to occur within healthcare settings.Comprehensive policies and repeated trainings on ethical conduct and professional boundaries, need to be implemented to prevent and respond to instances of sexual violence, and prioritize survivor-centered approaches that promote safety, dignity, and justice.The policies also need to promote a culture of zero tolerance for abuse, and establish effective mechanisms for identifying, reporting, and addressing incidents of abuse by both patients and staff.Additionally, efforts to challenge societal attitudes and beliefs that perpetuate victim-blaming and stigma are essential to creating a culture of accountability and support for survivors to promptly report cases of abuse.Further research is needed to explore the intersection of gender, power, and healthcare-related sexual abuse, with a focus on validating and expanding upon the hypotheses generated by this study.
In conclusion, the incidence of rape of patients by healthcare providers within healthcare settings is a distressing occurrence that demands immediate attention [37,38].It is crucial that stakeholders involved with healthcare management and patients' care acknowledge the existence of this issue, raise awareness, and implement comprehensive measures to prevent and address cases of sexual assault.By prioritizing survivor-centered approaches, robust institutional policies, and transformative cultural change, it is possible to create healthcare environments that are truly safe, respectful, and supportive for all individuals seeking care.

Fig. 1
Fig. 1 Flowchart of selection of media publications accessible on the internet, of cases of rape in healthcare facilities.From Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ 2021;372:n71.doi: https://doi.org/10.1136/bmj.n71

Fig. 2
Fig. 2 Year of reporting of the 62 incidences of rape in healthcare institutions

Table 1 ,
there were 66 persons involved in the 62 reported cases.Of these 21(31.8%)